Enhancing Emotional Regulation With Resonance Frequency Paced Breathing Training

1. Enhancing Emotional Regulation With Resonance Frequency Paced Breathing Training Milton Z. Brown, Ph.D. Alliant International University DBT Center of San Diego www.dbtsandiego.com

2. Physiology of Emotion Dysregulation Research Studies Implementation of Paced Breathing Topics 2

3. When a threat is perceived: sympathetic arousal parasympathetic/vagal withdrawal (reduced HRV) When the threat has passed: parasympathetic re-activation (vagal brake) Low parasympathetic activity (low HRV) increases emotional reactivity/sensitivity In BPD: more vagal withdrawal, more often (low HRV) slower vagal re-activation => emotions linger Emotion Dysregulation Autonomic Nervous System 3

5. Austin et al. (2007) N=20 baseline HRV: BPD = control (low power) HRV after emotion films: BPD < control Kuo & Linehan (2009) N=60 baseline HRV: BPD < social anxiety HRV after emotion films: BPD = control the films may not have been effective enough Weinberg et al. (2009) N = 40 baseline HRV: BPD < control HRV after social stressor: BPD = control Emotion Dysregulation in BPD Autonomic Nervous System 5

6. Higher levels of stress reactivity cortisol reactivity (Johnson et al. 2002) startle potentiation (Ruiz-Padial et al. 2003) Worse executive function performance sustained attention working memory inhibition/flexibility (e.g., Stroop, Go-NoGo) mental persistence (two studies) during stressors (Hansen et al. 2009) Problems Associated with Low HRV 6

7. Focus on Emotion Regulation Reduce vulnerability to emotion triggers exercise, and balanced eating and sleep exposure therapy Reduce intensity of emotion episodes more than distraction is needed Increase emotional tolerance mindfulness block avoidance Act effectively despite emotional arousal DBT Strategies 7

8. Goals of Relaxation Training Reduce vulnerability to emotion triggers Skills for regulating emotions when triggered reduce emotional arousal feel better activate parasympathetic system emotion tolerance more capacity for effective behavior sustained effort (“will power”) problem-solving cognitive abilities

9. Goal 1: Increase general levels of HRV Goal 2: Increase ability to reverse vagal withdrawal (recover from stressors) Activities that strengthen baroreflexes: increase HRV in general improve recovery from vagal withdrawal improve executive functioning improve mood incongruent behaviors Goals of Relaxation Training 9

10. HRV-linked self-regulation is like a muscle: Regular HRV training increases ability to activate HRV in specific situations HRV-linked emotion coping behaviors are effortful and hard to sustain for long periods become less effective after prolonged use HRV “depletes” and improves with rest Heart Rate Variability 10

11. Randomized Studies of HRV 11

12. HRV manipulations Two experiments failed to worsen HRV Exercise improved HRV and execute function tasks (Hansen et al. 2004) RF breathing => calm, HRV (Vaschillo, 2006) HRV-BF (RCTs were HRV-BF home practice) 15 min. => calm, HRV (Sherlin, 2009) 4 wks (20 min 5x/wk) => HRV and BDI (Zucker, 2009) 8 wks (15 min/wk) => HRV/BDI (Brown et al., 2009) reduction in PTSD symptoms (White, 2008) Randomized Studies of HRV 12

13. There are NO randomized studies of HRV-BF or exercise for BPD Studies need to confirm improvements in: Resting HRV and global symptoms When stressors occur: HRV vagal withdrawal recovery subjective arousal/tolerance executive functioning abilities effort persistence Needed HRV Studies 13

14. Implementation of Paced Breathing 14

15. Resonance Frequency Breathing slow pace: about 5-6 breaths per minute breathing synchronized with RSA oscillations in HR and blood pressure (~5-6 cycles/min.) largest possible HR decrease on each exhale smooth/coherent HR oscillations (waves) need to verify with visual HR feedback Prolonged RF breathing may create better autonomic balance better than PMR

16. 12 breaths per minute

17. 7 breaths per minute

18. 5 breaths per minute

19. 5 breaths/min. HR/BP Synchrony

20. primarily the lower abdomen (diaphragm) exhale longer than inhale (4 sec in, 6 sec out) pursed lips to slow down the exhale exhaling slows HR (vagal break) exhaling at RF pace activates most vagal break visual feedback can maximize RSA HRV and breathing-HR synchrony biofeedback may maximize placebo effect Resonance Frequency Breathing

21. Design N = 15 BPD participants Single-group pre-post design 8-10 biofeedback sessions (1 hr) asked to practice for 20 min. per day PANAS, BSL, BAI, BDI, DERS, HRV BPD RF Breathing Feasibility Study

22. Outcomes (N = 15) 80% (12) easily mastered breathing by 2nd session; without pacer by 3rd or 4th session 1 had a few more sessions to develop mastery 20% (3 of 15) did not achieve mastery 2 dropped out (did not like breathing) Among the 13 completers: 62% (8) practiced consistently 62% (8) liked breathing and reported it helpful 8% (1) did not like the breathing 23% (3) did not report whether it was helpful BPD RF Breathing Feasibility Study

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25. Slow Breathing Training Phase 1: assess baseline RSA HRV and resonance frequency (RF) Phase 2: practice breathing at RF pace with pacing stimulus, visual feedback, or counting Phase 3: breathe at RF pace autonomously Phase 4: quickly engage RF breathing when distressed (during or immediately following emotion triggers) Phase 5: confirm quick RSA HRV recovery

26. Slow Breathing Training Phase 1: Assessment baseline RSA HRV at rest when attempting to relax when attempting to recover from stressor determine resonance frequency (RF) 2 minute recordings of HR oscillations at each pace record size of HR reductions on exhale at each pace 7 bpm, 6.5, 6.0, 5.5, 5.0, 4.5, and 4.0 bpm

28. 2 Minute Breathing Test

29. 10 bpm 60 s 8.5 1:10 min 7.5 1:20 7.0 1:25 6.5 1:30 6.0 1:40 5.5 1:50 5.0 2:00 4.5 2:13 min 10 breath Pacing Test 29

30. Slow Breathing Training Problems Patient cannot breathe slowly enough take a more gradual approach take in more air with each breath Patient gets light-headed or dizzy and stops slow breathing take in less air Patient breathes primarily from upper chest lay down with book on abdomen Patient cannot engage RF breathing without prompts or heart rate feedback much more practice (e.g., 20 min/day) Patient cannot engage RF breathing when distressed practice in context (e.g., during exposure therapy)

31. Weinberg, Klonsky, Hajcak (2009). Autonomic impairment in borderline personality disorder. Brain and Cognition. Austin, Riniolo, Porges (2007). Borderline personality disorder and emotion regulation. Brain and Cognition Kuo & Linehan (2009). Disentangling emotion processes in borderline personality disorder. Journal of Abnormal Psychology Segerstrom & Solberg (2007). Heart rate variability reflects self-regulatory strength, effort, and fatigue. Psychological Science Reynard, Gevirtz, Brown, Boutelle, Berlow (2011). Heart rate variability as a marker of self-regulation. Applied Psychophysiology and Biofeedback Sherlin, Gevirtz, Wyckoff, Muench (2009). Effects of respiratory sinus arrhythmia biofeedback versus passive biofeedback control. International Journal of Stress Management References

32. Dale, Carroll, Galen, Hayes, Webb, Porges (2009). Abuse history is related to autonomic regulation to mild exercise and psychological wellbeing. Applied Psychophysiology and Biofeedback, 34(4), 299-308 References